LARGO, Md. - Kaiser Permanente says a piece of equipment may not have been thoroughly disinfected and sterilized during the colonoscopy or upper endoscopy of 23 people at its medical facility in Largo.

The patients were all contacted by their doctors this week after the health care provider discovered a defect in its equipment, which may have affected the effectiveness of the sterilization process.

All 23 patients are being asked by Kaiser Permanente to return to undergo screening tests for possible risks of illnesses such as HIV and hepatitis C after the equipment was used for their procedures in April.

Kaiser Permanente said in a statement:

“We are reaching out to 23 patients to let them know that a piece of endoscopy equipment at our Largo Medical Center had a defect that might have kept it from being thoroughly disinfected. Kaiser Permanente follows nationally recommended protocols for the cleaning and disinfection of all equipment used during procedures to ensure the safety of our patients and that all potentially transmissible infectious agents have been removed. The scope in question was disinfected following the recommended protocols before its use. However, after discovering the defect and conducting subsequent analysis, we determined that we cannot guarantee that the sterilization process was fully effective.

“Even though our physicians believe the risk of illness in this situation is minimal, gastroenterologists are contacting the 23 members who underwent a colonoscopy/upper endoscopy at the Largo Endoscopy Unit to explain the situation and ask them to come in for some screening tests. Each member’s primary care physician will work closely with them to ensure appropriate care is provided. All potentially affected members will also receive a letter from Kaiser Permanente. Concerned Kaiser Permanente members should call 1-800-777-7904.

“At Kaiser Permanente, the health and safety of our members is our absolute top priority. We are reaching out to all potentially impacted members and are committed to ensuring that this does not happen again.”

FOX 5 spoke to Alan Lipschultz of HealthCare Technology Consulting about how this could have been avoided and whether there is anything patients can do to protect themselves.

“There are certifications out there in terms of the joint commission and reviews that are done through reputable sources as how the institution does, but that still doesn't prevent even reputable institutions from having problems like this,” he said. “There are a lot of human factors that go into the cleaning of a scope, but the fact that the defect or at least they are saying that there is a defect, is a complication nobody is expecting. Was there an adequate examination of the device beforehand to find the defect? That is the kind of thing that they need to be doing, and probably working with the manufacturer of the device also to see how should this defect have been caught.”

Lipschultz also said there is a risk you take at any medical facility, but the risk of not undergoing these procedures outweigh the risk of something like this happening.